2009NCCN子宫肿瘤指南（英文版）

Continue NCCN Clinical Practice Guidelines in Oncology™ Uterine Neoplasms V.1.2010 www.nccn.org Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Uterine Neoplasms Panel Members � � Gynecologic oncology † Medical oncology ‡ Hematology § Radiotherapy/Radiation oncology Pathology * Writing committee memberContinue NCCN Guidelines Panel Disclosures Uterine Neoplasms * * * Benjamin E. Greer, MD/Co-Chair Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Wui-Jin Koh, MD/Co-Chair Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance � � � � � § † † Nadeem R. Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center Sachin M. Apte, MD, MS H. Lee Moffitt Cancer Center & Research Institute Michael A. Bookman, MD Fox Chase Cancer Center Robert E. Bristow, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Susana M. Campos, MD, MPh, MS Dana-Farber/Brigham and Women’s Cancer Center John Chan, MD UCSF Helen Diller Family Comprehensive Cancer Center Kathleen R. Cho, MD University of Michigan Comprehensive Cancer Center Larry Copeland, MD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Marta Ann Crispens, MD Vanderbilt-Ingram Cancer Center Nefertiti duPont, MD, MPH Roswell Park Cancer Institute Patricia J. Eifel, MD The University of Texas M. D. Anderson Cancer Center Warner K. Huh, MD � � � � � § § � University of Alabama at Birmingham Comprehensive Cancer Center Daniel S. Kapp, MD, PhD Stanford Comprehensive Cancer Center John R. Lurain, III, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Mark A. Morgan, MD Fox Chase Cancer Center Robert J. Morgan, Jr., MD City of Hope Comprehensive Cancer Center Nelson Teng, MD, PhD Stanford Comprehensive Cancer Center � � † ‡ § Steven W. Remmenga, MD UNMC Eppley Cancer Center at The Nebraska Medical Center R. Kevin Reynolds, MD University of Michigan Comprehensive Cancer Center Angeles Alvarez Secord, MD William Small, Jr., MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � � � Duke Comprehensive Cancer Center Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. This manuscript is being updated to correspond with the newly updated algorithm. These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. Table of Contents Uterine Neoplasms Uterine Sarcoma Endometrial Carcinoma NCCN Uterine Neoplasms Panel Members S Uterine Neoplasms (UN-1) Disease limited to the uterus (ENDO-1) Suspected or gross cervical involvement (ENDO-2) Suspected extrauterine disease (ENDO-3) Surveillance (ENDO-9) Recurrence (ENDO-9) Papillary serous, Clear cell carcinoma, Carcinosarcoma (ENDO-11) Hysterectomy (ENDO-A) Systemic Therapy for Recurrent, Metastatic or High-risk Disease (ENDO-B) Disease limited to the uterus (UTSARC-1) Known or suspected extrauterine disease (UTSARC-1) Low-grade Endometrial stromal sarcoma (ESS) (UTSARC-2) High-grade undifferentiated sarcoma (HGUD) and Leiomyosarcoma (UTSARC-3) ummary of Guidelines Updates Surveillance (UTSARC-4) Recurrence (UTSARC-4) Systemic Therapy for Uterine Sarcoma (UTSARC-A) Uterine Sarcoma Classification (UTSARC-B) Principles of Radiation Therapy (UN-A) Guidelines Index Print the Uterine Cancers Guideline For help using these documents, please click here Staging Discussion References Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. See The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. NCCN To find clinical trials online at NCCN member institutions, click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Uterine Neoplasms Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Summary of changes in the 1.2010 version of the Uterine Neoplasms Guidelines from the 2.2009 version include: Summary of the Guidelines updates UPDATES Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Endometrial Carcinoma Age : Footnote “g”: Potential adverse risk factors include the following: > 60 y...,” changed to “Potential adverse risk factors include the following: ...” � ( )ENDO-4 ( ) ( ) ENDO-B UTSARC-A Systemic Therapy for Recurrent, Metastatic or High-Risk Disease Chemotherapy Regimens: “Ixabepilone may be used as a single agent for second line treatment of patients (category 2B)” was added. Chemotherapy Regimens: First bullet: After “doxorubicin” the following phrase was removed “(most active single agent for LMS)”. Third bullet: The panel clarified all of the single agent options as category 2B. � � Uterine Sarcoma: � � Uterine Neoplasms Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. UN-1 INITIAL EVALUATION INITIAL CLINICAL FINDINGS � � � � � � � H&P CBC, platelets Endometrial biopsy Chest x-ray Current cervical cytology consistent with LFT/renal function tests/chemistry profile Consider genetic counseling for patients with a significant family history Optional: NCCN Cervical Screening Guidelines Pathology review Disease limited to uterus Suspected or gross cervical involvement Papillary serous or clear cell carcinoma Suspected extrauterine disease See Treatment for Papillary Serous or Clear Cell Carcinomas of the Endometrium or Carcinosarcoma (ENDO-11) See Primary Treatment (ENDO-1) See Primary Treatment (ENDO-2) See Primary Treatment (ENDO-3) Pure endometrioid Epithelial carcinoma Stromal/mesenchymal tumors � � � Low-grade endometrial stromal sarcoma (ESS) High-grade undifferentiated sarcoma (HGUD) Leiomyosarcoma (LMS) Carcinosarcomaa,b a b Staged aggressively, should be treated as a high-grade endometrial cancer. Also known as malignant mixed mesodermal tumor or and including those with either homologous or heterologous stromal elements.malignant mixed Müllerian tumor All staging in guideline is based on FIGO staging. (See ST-1) Disease limited to uterus Known or suspected extrauterine disease See Primary Treatment (UTSARC-1) Uterine Neoplasms Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ENDO-1 INITIAL CLINICAL FINDINGS Disease limited to the uterus (endometrioid histologies)a Medically inoperable Operable PRIMARY TREATMENT Tumor-directed RTb a for clarification of uterine neoplasms. b d c American College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. See (UN-1 See Hysterectomy (ENDO-A) ) . See Principles of Radiation Therapy (UN-A). See Surveillance (ENDO-9) Total hysterectomy and bilateral salpingo- oophorectomy (TH/BSO)c � � Cytology Lymph node dissection (not random sampling)d Pelvic lymphadenectomy Para-aortic lymphadenectomy � � Adjuvant Treatment for completely surgically staged: � � � � Stage I (See ENDO-4) Stage II (See ENDO-5) Stage IIIA (See ENDO-6) Stage IIIB-IV (See ENDO-7) See (ENDO-8) Incompletely surgically staged Endometrial Carcinoma Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ENDO-2 Suspected or gross cervical involvement (endometrioid histologies)a Negative result ADDITIONAL WORKUP PRIMARY TREATMENT Consider cervical biopsy or MRI Positive result or gross involvement e Operable Radical hysterectomy and bilateral salpingo- oophorectomy (RH/BSO) or RT: 75-80 Gy to point A (category 2B) c � � Cytology Lymph node dissection (not random sampling)d Pelvic lymphadenectomy Para-aortic lymphadenectomy � � f Inoperable Tumor-directed RTb TH/BSO Para-aortic lymph node dissection c See Surveillance (ENDO-9) INITIAL CLINICAL FINDINGS TH/BSO Cytology Lymph node dissection (not random sampling)d Pelvic lymphadenectomy Para-aortic c � � � � lymphadenectomy Adjuvant treatment for completely surgically staged: � � � � Stage I (See ENDO-4) Stage II (See ENDO-5) Stage IIIA (See ENDO-6) Stage IIIB-IV (See ENDO-7) Clear demonstration of cervical stromal involvement. a for clarification of uterine neoplasms. Based on summation of conventional external-beam fractionation and low-dose-rate brachytherapy equivalent. b c d f American College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. e See (UN-1) See Hysterectomy (ENDO-A) See Principles of Radiation Therapy (UN-A). . See (ENDO-8) Incompletely surgically staged Endometrial Carcinoma Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Suspected extrauterine disease (endometrioid histologies)a None Intra-abdominal: � � � � � Ascites Omentum Nodal Ovarian Peritoneal Extrauterine pelvis: � � � � Vaginal Bladder Bowel/rectum Parametrial Extra-abdominal/liver See Primary Treatment (disease limited to uterus) (ENDO-1) RT ± surgery + brachytherapy ± chemotherapy � � CA-125 MRI/CT, as clinically indicated TH/BSO + cytology ± maximal debulking ± pelvic and para-aortic lymph node dissection c d Consider palliative TH/BSO ± RT ± hormonal therapy ± chemotherapy Adjuvant treatment for completely surgically staged: � � Stage IIIA (See ENDO-6) Stage IIIB-IV (See ENDO-7) See Surveillance (ENDO-9) ADDITIONAL WORKUP PRIMARY TREATMENTINITIAL CLINICAL FINDINGS a for clarification of uterine neoplasms. c dAmerican College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. See (UN-1) See Hysterectomy (ENDO-A). ENDO-3 Endometrial Carcinoma Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ENDO-4 CLINICAL FINDINGS G1 Stage IA G2 Stage IB ( 50%) myometrial invasion � Stage IC (> 50%) myometrial invasion Adjuvant treatment for completely surgically staged: Stage I G3i,j b g i j Potential adverse risk factors include the following: Age, positive lymphovascular invasion, tumor size, lower uterine (cervical/glandular) involvement. hAdjuvant therapy determinations are made on the basis of pathologic findings. The role of adjuvant chemotherapy in invasive high-grade uterine confined disease is the subject of current studies. (Creutzberg, CL Clinical Trial: Chemotherapy and Radiation Therapy Compared With Radiation Therapy Alone in Treating Patients With High-Risk Stage I, Stage II, or Stage III Endometrial Cancer; Clinical trial summary from the National Cancer Institute's PDQ® database. Study ID Numbers: CDR0000521447; CKTO-2006-04; ISRCTN14387080; CKTO-PORTEC-3; EU- 20664--- . Hogberg T, Rosenberg P, Kristensen G, et al. A randomized phase-III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-risk endometrial cancer (NSGO-EC-9501/EORTC 55991) [abstract]. J Clin Oncol 2007;25:5503). See Principles of Radiation Therapy (UN-A) http://clinicaltrials.gov/ct/show/NCT00411138;jsessionid=2309E60C1051E921B4E2614F2BE708A4?order=9 . See Systemic Therapy for Recurrent, Metastatic, or High-Risk Disease (ENDO-B). See Surveillance (ENDO-9) ADVERSE RISK FACTORSg Adverse risk factors present Adverse risk factors not present Adverse risk factors present Adverse risk factors not present Adverse risk factors present Adverse risk factors not present HISTOLOGIC GRADE/ADJUVANT TREATMENTb,h,i,j Observe or Vaginal brachytherapy Observe or Vaginal brachytherapy Observe or Vaginal brachytherapy and/or Pelvic RT Observe or Vaginal brachytherapy and/or Pelvic RT Observe or Pelvic RT and/or Vaginal brachytherapy ± chemotherapy (category 2B for chemotherapy) Observe Observe or Vaginal brachytherapy Observe or Vaginal brachytherapy Observe Observe or Vaginal brachytherapy and/or pelvic RT (category 2B for all options) Observe or Vaginal brachytherapy and/or Pelvic RT Observe Observe or Vaginal brachytherapy Observe Observe Observe or Vaginal brachytherapy Observe aginal brachytherapy and/or Pelvic RT or V Observe or Vaginal brachytherapy and/or Pelvic RT Endometrial Carcinoma Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ENDO-5 Stage IIA Stage IIB Pelvic RT + vaginal brachytherapy Pelvic RT + vaginal brachytherapy ± chemotherapy (category 2B for chemotherapy) Pelvic RT + vaginal brachytherapy b h i j k Adjuvant therapy determinations are made on the basis of pathologic findings. Observation or vaginal brachytherapy is an option for patients with Stage II disease who are post primary radical hysterectomy, with negative surgical margins and no evidence of extrauterine disease. The role of adjuvant chemotherapy in invasive high-grade uterine confined disease is the subject of current studies. (Creutzberg, CL Clinical Trial: Chemotherapy and Radiation Therapy Compared With Radiation Therapy Alone in Treating Patients With High-Risk Stage I, Stage II, or Stage III Endometrial Cancer; Clinical trial summary from the National Cancer Institute's PDQ® database. Study ID Numbers: CDR0000521447; CKTO-2006-04; ISRCTN14387080; CKTO-PORTEC-3; EU- 20664--- . Hogberg T, Rosenberg P, Kristensen G, et al. A randomized phase-III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-risk endometrial cancer (NSGO-EC- 9501/EORTC 55991) [abstract]. J Clin Oncol 2007;25: 5503). See Principles of Radiation Therapy (UN-A) http://clinicaltrials.gov/ct/show/NCT00411138;jsessionid=2309E60C1051E921B4E2614F2BE708A4?order=9 . See Systemic Therapy for Recurrent, Metastatic, or High-Risk Disease (ENDO-B). CLINICAL FINDINGS Adjuvant treatment for completely surgically staged: Stage IIk G1 G2 G3i,j HISTOLOGIC GRADE/ADJUVANT TREATMENTb,h,i,j See Surveillance (ENDO-9) Optional vaginal brachytherapy for all patients; for recommendations based on findings in the uterine fundus (See ENDO-4) Endometrial Carcinoma Guidelines Index Uterine Neoplasms TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Version 1.2010, 10/05/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Adjuvant treatment for completely surgically staged: Stage IIIA All other IIIA ObservelObservel Chemotherapy ± RT or Tumor-dir